Advertisement

Supporting Complex Dynamic Health Journeys Using Conversation to Avert Hospital Readmissions from the Community: An Ecological Perspective Incorporating Interoception

  • Carmel Martin
  • Joachim P. Sturmberg
  • Keith Stockman
  • Donald Campbell
  • Lucy Hederman
  • Carl Vogel
  • Kevin Smith
Chapter

Abstract

Hospital readmissions are the consequence of an individual unstable health journeys in the context of their local health services and community configurations. The Patient Journey Record System (PaJR) has developed a conversational approach with care guides and clinician coaches who support such health journeys irrespective of condition and location.

This chapter explores the pilot deployments of PaJR, that were initially validated in rural Ireland communities (IPCC), followed by MonashWatch (MW), a hospital-based readmission program in multicultural inner-city Melbourne, Australia. Despite differences in language, culture, community and health services settings, and recruitment strategies (GP invite vs cold calling) and uptakes rates (IPCC > 90% and MW 60%), self-rated health and rates of acute problems (red alerts) requiring prompt intervention were similar in both groups. Typical presentations were different in the two groups with IPCC presenting with age-related multimorbidity problems and MW with a cluster of pain, depression, and drug and alcohol problems in the context of psychosocial and environmental problems with many more instances of not coping (pink alerts). PaJR was well received with very low dropout rates in either group. This approach identified problems, generally amenable to intervention, but many psychosocial problems, particularly in MW, were challenging to solve within existing health service structures and resources.

In conclusion supporting complex health journeys through conversations using lay care guides and an adaptive systems approach is feasible in at least two very different settings and patient groups.

Notes

Acknowledgements

Deirdre Grady, Laurence Gaughan, Brendan O’Shea, John Kellett, Narelle Hinkley, Damian Byrne, John-Paul Smith, Michael Jaurigue, Basem Youry, and all the wonderful care guides in Ireland and Melbourne.

References

  1. 1.
    Robertson TM, Lofgren RP. Where population health misses the mark: breaking the 80/20 rule. Acad Med. 2015;90(3):277–8.CrossRefGoogle Scholar
  2. 2.
    Robinson RL, Grabner M, Palli SR, Faries D, Stephenson JJ. Covariates of depression and high utilizers of healthcare: impact on resource use and costs. J Psychosom Res. 2016;85:35–43.CrossRefGoogle Scholar
  3. 3.
    Legge J. A record of Buddhistic kingdoms: being an account by the Chinese monk Fâ-Hien of his travels in India and Ceylon (399-414 CE) in: search of the Buddhist books of discipline, 1886. Translated and annotated with a Corean recension of the Chinese text by Fâ-Hien, ca. 337-ca. 422. https://archive.org/details/recordofbuddhist00fahsuoft.
  4. 4.
    Institute of Medicine. The evolving role of hospital-based emergency care. In: Hospital-based emergency care: at the breaking point. Washington, DC: The National Academies Press; 2007. p. 37–40.Google Scholar
  5. 5.
    D’Souza S, Guptha S. Preventing admission of older people to hospital. BMJ. 2013;346:f3186.CrossRefGoogle Scholar
  6. 6.
    Rosen R. Life itself: a comprehensive inquiry into the nature, origin, and fabrication of life. New York: Columbia University Press; 1991.Google Scholar
  7. 7.
    Li X, Dunn J, Salins D, Zhou G, Zhou W, Schüssler-Fiorenza Rose, SM, Perelman D, Elizabeth Colbert E, Runge R, Rego S, Sonecha R, Datta S, McLaughlin T, Snyder, MP. Digital health: tracking physiomes and activity using wearable biosensors reveals useful health-related information. PLoS Biol. 2017;15(1):e2001402.CrossRefGoogle Scholar
  8. 8.
    Olde Rikkert MG, Dakos V, Buchman TG, Boer R, Glass L, Cramer AO, Levin S, van Nes E, Sugihara G, Ferrari MD, Tolner EA, van de Leemput I, Lagro J, Melis R, Scheffer M. Slowing down of recovery as generic risk marker for acute severity transitions in chronic diseases. Crit Care Med. 2016;44(3):601–6.CrossRefGoogle Scholar
  9. 9.
    Scheffer M. Critical transitions in nature and society. Princeton: Princeton University Press; 2009.Google Scholar
  10. 10.
    Bloss CS, Wineinger NE, Peters M, Boeldt DL, Ariniello L, Kim JY, Sheard J, Komatireddy R, Barrett P, Topol, EJ. A prospective randomized trial examining health care utilization in individuals using multiple smartphone-enabled biosensors. PeerJ. 2016;4:e1554.PubMedGoogle Scholar
  11. 11.
    Lyon ML. Psychoneuroimmunology: the problem of the situatedness of illness and the conceptualization of healing. Cult Med Psychiatry 1993;17(1):77–97.CrossRefGoogle Scholar
  12. 12.
    Shubin S, Rapport F, Seagrove A. Complex and dynamic times of being chronically ill: beyond disease trajectories of patients with ulcerative colitis. Soc Sci Med. 2015;147:105–12.CrossRefGoogle Scholar
  13. 13.
    Craig AD. Interoception: the sense of the physiological condition of the body. Curr Opin Neurobiol. 2013;13(4):500–5.CrossRefGoogle Scholar
  14. 14.
    Jylhä M. What is self-rated health and why does it predict mortality? Towards a unified conceptual model. Soc Sci Med. 2009;69(3): 307–16.CrossRefGoogle Scholar
  15. 15.
    Public Policy.IE. Expenditure and outputs in the Irish health system: a cross country comparison, 2012. http://www.publicpolicy.ie/expenditure-and-outputs-in-the-irish-health-system-a-cross-country-comparison/.
  16. 16.
    Martin CM, Grady D, Deaconking S, McMahon C, Zarabzadeh A, O’Shea B. Complex adaptive chronic care - typologies of patient journey: a case study. J Eval Clin Pract. 2011;17(3):520–4.CrossRefGoogle Scholar
  17. 17.
    Martin CM, Vogel C, Grady D, Zarabzadeh A, Hederman L, Kellett J, Smith K, O’Shea B. Implementation of complex adaptive chronic care: the patient journey record system (PaJR). J Eval Clin Pract. 2012;18(6):1226–34.CrossRefGoogle Scholar
  18. 18.
    Martin CM, Biswas R, Joshi A, Sturmberg JP. Patient journey record systems (PaJR): the development of a conceptual framework for a patient journey system. In: Biswas R, Martin CM, editors. User-driven healthcare and narrative medicine: utilizing collaborative social networks and technologies, vol 1. Hershey, PA: IGI Global; 2010. p. 75–92.CrossRefGoogle Scholar
  19. 19.
    Martin CM. What matters in “multimorbidity”? Arguably resilience and personal health experience are central to quality of life and optimizing survival. J Eval Clin Pract. 2016;https://doi.org/10.1111/jep.12644.
  20. 20.
    Froese T. Life is precious because it is precarious: individuality, mortality and the problem of meaning. In: Dodig-Crnkovic G, Giovagnoli R, editors. Representation and reality in humans, other living organisms and intelligent machines. Studies in applied philosophy, epistemology and rational ethics, vol 28. Cham: Springer; 2017. p. 33–50. https://doi.org/10.1007/978-3-319-43784-2_3.Google Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Carmel Martin
    • 1
  • Joachim P. Sturmberg
    • 2
    • 3
  • Keith Stockman
    • 1
  • Donald Campbell
    • 1
  • Lucy Hederman
    • 4
  • Carl Vogel
    • 5
  • Kevin Smith
    • 6
  1. 1.Monash Medical Centre, General Medicine OfficesClaytonAustralia
  2. 2.School of Medicine and Public HealthUniversity of NewcastleNewcastleAustralia
  3. 3.Foundation PresidentInternational Society for Systems and Complexity Sciences for HealthNewcastleAustralia
  4. 4.Centre for Health Informatics (CHI)Trinity College Dublin, The University of DublinDublin 2Ireland
  5. 5.Trinity Centre for Computing and Language StudiesTrinity College Dublin, The University of DublinDublin 2Ireland
  6. 6.Research Computing Centre Level 5The University of QueenslandSt LuciaAustralia

Personalised recommendations